Venous Access

Selecting an appropriate vascular access device (VAD) requires collaboration among the interprofessional team, the patient, and the patient’s caregiver to match the best available technology to the needs and special conditions of the individual patient.

The Infusion Nurses Society identifies the following key considerations for selecting the appropriate VAD:

Patient factors	VAD factors
patient’s age vascular characteristics comorbidities history of infusion therapy ability and resources available to care for the device	prescribed therapy and duration of treatment VAD engineering and material properties concurrent infusion compatibility preservation of vascular integrity smallest outer diameter with the fewest number of lumens the safest, least invasive device needed for the prescribed therapy (Gorski et al. 2021)

• Centrally Inserted Central Catheter (CICC) - Single or multiple lumen
  • CICCs require insertion by a physician.
  • CICCs have the advantage of rapid insertion for the emergent delivery of fluid resuscitation.
  • CICCs are available in larger lumen sizes allowing greater infusion volume and more reliable sample withdrawal than peripheral catheters. Some have been engineered to allow high pressure infusion of contrast media. Others can be tunneled from the insertion site to a subcutaneous access port. Tunneled CICCs can have a longer service life and a lower risk of infection but managing an infected tunneled CICC is more difficult than removing a temporary catheter.
  • CICCs have a greater risk of major insertion complications including: pneumothorax, air embolism, arterial puncture, hemorrhage, hematoma.
  • Common insertion sites include
• Right internal jugular and left subclavian veins provide the most direct path to the right atrium and terminate in the superior vena cava.
• Femoral vein is rarely used as a CVC insertion site because it is associated with increased risk of catheter related blood stream infections (Lorente 2005). The femoral vein is a compressable site and may be used if the patient has a coagulopathy.
  
  
• Peripherally Inserted Central Catheter (PICC) - can be inserted into the basilic, cephalic, median cubital or brachial veins, usually above the antecubital fossa with the tip terminating in the lower 1/3 of the superior vena cava (SVC). PICCs placement in the SVC provides better hemodilution than shorter peripheral catheters and are therefore indicated for hypotonic, isotonic, hypertonic and vesicant therapy. Some PICCs are engineered to allow additional functions including high pressure injection (up to 300 psi) and central venous pressure (CVP) monitoring. CVP monitoring should be done using a 20 gauge or larger PICC.
  
  To reduce the risk of thrombosis, ultrasound measurement of the vein should offer a catheter-to-vein ratio of 45% or less before insertion.
  
  PICC lines can remain in place for up to 1 year provided that there are no complications.
  
  • In the recent past, PICCs were associated with high incidence of central line associated blood stream infections but that risk is likely diminished due to industry wide implementation of patient safety guidelines including the use of maximal sterile barrier precautions during insertion and improved skin prep and dressing techniques.
  • A systematic review of 56 studies by Mussa, Alsbrook and Hutcheson revealed:
    • A statistically significant improvement in patient satisfaction with PICCs versus CICCs or PIVCs and fewer venipunctures for successful insertion compared with PIVCs
    • Across all studies the rate of removal due to complications were 3.5% to 48% with PICCs compared to 67% to 81.2% with PIVCs and 26% to 78% with CICCs.
    • The proportion of patients reporting catheter migration/dislocation was 0% to 7.7% with PICCs compared to 9.6% to 15% with CICCs.
    • The rate of venous thrombosis was 0% to 27.2% for PICC versus 0% to 9.6% for CICC, with individual studies reporting significant differences (Mussa 2019).

Peripheral intravenous catheters are VADs whose infusion tips reside outside of the superior or inferior vena cava.

• Short peripheral catheter - Commonly referred to as an IV catheter, are of two type: winged steel needles (butterflies or scalp needles) and short over-the needle catheters usually <3 inches in length.
• Midline catheter - Peripheral intravenous catheter which is inserted into the basilic, cephalic, or brachial veins usually above the antecubital fossa with the tip terminating not beyond the axillary vein. Midline catheters offer a longer dwell time and better hemodilution than the short peripheral IV catheters. Midline catheter dwell time is about 1-8 weeks. Midline catheters may be appropriate for delivery of isotonic or near isotonic solutions (250-350 meq/L) solutions with a pH of 5-9 (the same as shorter peripheral IV catheters). Midline catheters are not used for routine blood drawing. As with all long catheters, blood pressure cuffs or tourniquets should not be used on the arm where a midline catheter has been placed.
• Midclavicular catheter - Peripheral intravenous catheter which is inserted into the medial cubital or the basilic vein in the upper arm above the antecubital fossa with the tip terminating in the subclavian vein near the center point of the clavicle. Midclavicular placement is not recommended due to increased risk of thrombphebitis. A midclavicular catheter is considered a peripheral catheter and is therefore limited to delivery of isotonic or near isotonic solutions (250-350 meq/L) solutions with a pH of 5-9 (the same as shorter peripheral IV catheters).

References

Carrer S, Bocchi A, Bortolotti M, et al. Effect of different sterile barrier precautions and central venous catheter dressing on the skin colonization around the insertion site. Minerva Anestesiol 2005; 71:197–206

Gorski L.A., Hadaway L, Hagle M.E., Broadhurst D, Clare S, KleidonT, Meyer B.M., Nickel B., Rowley S., Sharpe E., Alexander M. (2021).  Infusion Therapy Standards of Practice, 8th Edition. Journal of Infusion Nursing. 44(1S):S1-S224

Lorente L, Henry C, Martín MM, Jiménez A, Mora ML. Central venous catheter-related infection in a prospective and observational study of 2,595 catheters. Crit Care. 2005;9(6)

Mussa B., Alsbrook K., Hutcheson R. (2019) Short- and Intermediate-Term Use of Peripherally Inserted Central Catheters in Europe: A Systematic Literature Review. Journal of the Association for Vascular Access (2019) 24 (4): 45–56.

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